Case Study: DM/CHD Version 7

1. Case Study: DM/CHDVersion 7 Erica Frost, Katlyn Rhodes Samantha Mallik, Onalee Neff

2. Patient • Chad, 28 year old high school graduate • Employed at a drug store • Doesn’t eat fruit and vegetables, only meals with minimal preparation • States abnormal thirst and hunger, and not feeling right • Admitted after found throwing up blood and barely responsive

3. Diet Assessment • Breakfast: • 2 strawberry poptarts • 1 glazed doughnut • 1 cup lowfat milk • Snack: • 2 cups of coffee • 1 fruit danish • Dinner: • 1 frozen dinner, Hungry man Salisbury Steak • 12 oz Mountain Dew • 1 slice white bread • 1 tsp. butter • Snack: • 5 slices pepperoni pizza • 5, 12 oz light beers

4. Diet Evaluation • 24 hour recall • 13 medium fat meat exchanges • 1 low fat milk exchange • 22.5 starch exchanges • 30 fat exchanges • Kcals: • Carbohydrates: 1398 • Protein: 666 • Fat: 2183 • Total: 4247

5. Anthropometry • Sex: Male • Age: 28 • Height: 5’10” (70 inches) • Weight: 230 lbs (104.5 kg) • Ideal body weight: 166 lbs • % Ideal body weight: 139 • BMI: between 33-34 • Interpretation: Obese

6. Acid/Base Balance • pH: 7.0 • Indicates acidosis • HCO3: 19 • Low • Interpretation: • Metabolic acidosis due to decrease in both pH and HCO3

7. Laboratory and physical data • Diabetes *polydypsia and increased hunger- evident by patients subjective history. *Weight=139% IBW, 33-34 BMI, upon admission *Diet high in trans fatty acids, contributed more than 7% of his daily fat intake *Hyperglycemia- evident by *Excessive alcohol consumption *Blood Glucose=560 *Too much food *Nausea *Diabetic Ketoacidosis (DKA)- evident by *Hyperglycemia *BP indicated Hypertension, which is a screening factor for diabetes *Pt. HCO3 and PCO2 levels are low

8. Laboratory and physical data • Cardiovascular disease * Stage 1 hypertension- BP= 150/90 *Poor diet- *Pt. diet is high in Saturated and Trans fatty acids, more than 50% of his current dietary intake are from Fat *Alcohol consumption- *more than 1-2 drinks a day increases BP * HDL lowers and Triglycerides raise *Obesity- *BMI: 33-34 *related to hypertension *glucose intolerance *Lab values- *Cholesterol: 325-elevated undesirable *LDL: 265-elevated *HDL: 40-borderline * elevated serum triglycerides *Microalbuminuria- *marker of increased cardiovascular risk and hypertension

9. Nutrition Diagnosis • Primary • Excessive fat intake related to frequent consumption of high risk lipids as evidenced by serum cholesterol level of 325 mg/dL, LDL of 265, and triglyceride of 300. • Secondary • Inappropriate intake of types of carbohydrates related to cultural practices that affect the ability to regulate carbohydrates consumed evidenced by hyperglycemia and random blood glucose level of 560.

10. Medications • Angiotension II • Avapro • Reduces hypertension by restricting narrowing of blood vessels • Lovastatin • Lowers cholesterol by blocking the production of cholesterol in the body • Reduces LDL and total cholesterol levels • Lovastatin combined with a cholesterol lowering diet plan is very effective

11. Metabolic Needs • Caloric needs • RMR= 10xwt(kg)+6.25xht(cm)-5x28+5 10x104.5+6.25x171.5-5x28+5 RMR= 1982 Kcal *Ambulatory *BMR=1.3x1982=2577 Kcal *Adjusted BMR=1.5x2577= 3866 Kcal * The Pt. calorie need is 2,577 Kcal

12. Metabolic Needs • Protein needs • Oral anabolic requirements *Protein needs 1.2-1.5g/Kg *Kg actual body wt. 104.54x1.2=125 104.54x1.5=157 g Protein/day • Grams of Nitrogen= 3866/150=25.7 g N required • 25.7N x 6.25=161 g Protein/day *The Pt. protein need is125-161 g Protein/day

13. Weight Loss Recommendation • Pt. IBW would be between 156-176lbs, this is a unrealistic short term goal, but could be a great long term goal for the patient to strive for *We do recommend a 5-10% reduction of his current weight of 230lbs/104.54 kg - with this reduction his weight would then be 207-218 lbs which is a realistic goal * We do not recommend any weight loss until the Pt. is in a stable condition

14. MNT Diet Prescription • The prescribed diet will consist of: • 55% of calories from carbohydrates • 20% of calories from protein • 25% of calories from fat • RMR= 2,577 kcal daily • 1417 kcal, 354 g carbohydrates • 515 kcal, 129 g protein • 644 kcal, 72 g fat

15. Patients Intake vs. Prescription • Calorie Consumption: • The pt. is currently consuming 4247 kcal • Prescription: Reduce caloric intake to 2558 kcal • Fat Intake: • Current Intake: 242 kcal (150 g) • Prescription: 70 kcal (35 g) • Protein Intake: • Current Intake:167 kcal (42 g) • Prescription: 129 kcal (32 g) • Fruit and Vegetable Intake: • We recommend he adds fruits and vegetables to his diet. • Meat: • We are encouraging him to eat lean meat instead of medium meat. • Milk: • We are encouraging a higher milk consumption

16. Exchange Plan

18. Fat Calculations • 11 starch exchanges : 11 g • 8 meat exchanges : 24 g • 7 fat exchanges : 35 g • 4 milk exchanges (skim) : 0 g • TOTAL : 70 g

19. Patient Goals • 5-10% weight reduction, short term goal • Glucose maintained to desirable limit • Achieve and maintain desirable lipid levels, through diet and therapeutic lifestyle changes • LDL cholesterol < 130-159 • HDL > 40 • Triglycerides < 150-199 • Cholesterol < 200-240 • Blood Pressure 130-139/85-89

20. Implementation & Monitoring • Patient will regularly see RD, 4-8 times within 6 month period. • Set timeline with RD for setting goals, and visits • Record 3-day or weekly diet record for first visit showing understanding of prescription • Lab values will be taken to ensure BGL and lipid profile are effectively being reduced.